Development and Validation of a Nutrition Transition Diet Score for Adolescents in India

Background Emerging research suggests changes in dietary patterns among adults and youth during the global nutrition transition, but there is no dietary score to measure the extent of nutrition transition that may be occurring. Objective To develop and validate an index‐based Nutrition Transition Diet Score for adolescents in India. Methods An evidence‐driven index‐based apriori Nutrition Transition Diet Score for adolescents was developed and validated against an exploratory factor analysis (EFA) derived Diet Score. The EFA with varimax rotation was used to derive dietary patterns from answers to a validated food frequency questionnaire provided by 198 adolescents in Vijayapura, India. The evidence‐driven index‐based Diet Score among adolescents who were in the top quartile (≥75 percentile) of the main dietary pattern were compared using diet score means to the rest of the group. Results The apriori index‐based Nutrition Transition Diet Score (range 0 – 10) included six food groups: fried foods, sugar‐sweetened beverages, dairy, fruits and vegetables, and bread, and four nutrients, namely total dietary fat, saturated fat, cholesterol, and simple sugars ( table 1). The Spearman correlations between the index‐based Diet Score and EFA‐driven Diet Score was high (r=0.68, p <0.0001). Among the adolescents, the mean evidence‐driven index‐based Nutrition Transition Diet Score was 4.7 ± 1.1. The following three dietary patterns were identified using EFA: the transition ‘westernized’ pattern (factor loadings >4 for breads, fried foods, processed foods, sugar‐sweetened beverages (fruits juices and carbonated beverages), and sweets and desserts), the animal‐source pattern (factor loadings >4 for egg, lean meat, and red meat), and the traditional ‘Indian’ pattern (factor loadings >4 for grains, fruits and vegetables, dairy, sugar, traditional fried foods, and ghee) ( table 2). The loading of traditional fried foods on both traditional and transition patterns indicate that as diets may become more ‘westernized’, this food group may continue to remain as one of the main components of the diet. The mean index‐based Diet Score was significantly higher (p< 0.0001) among adolescents in the upper quartile of the transition pattern (score range: 4–8) when compared to the rest (score range: 1–6) ( table 3). This shows that the evidence‐driven index‐based Nutrition Transition Diet Score is valid against an exploratory factor analysis (EFA) derived Diet Score for adolescents. Conclusion The validated index‐based Nutrition Transition Diet Score can be used to measure nutrition transition among adolescents in India. To our knowledge, this is the first diet score to assess the extent of nutrition transition. Support or Funding Information Nida Shaikh was supported by funding from the Fogarty International Center of the National Institutes of Health (award number 1‐R25 TW009337‐01). 1 Components of the Index‐based Nutrition Transition Diet ScoreComponents of the evidence‐driven Nutrition Transition Diet Score Criteria for Score 1 (Indicates Nutrition Transition) Criteria for score 0 (Indicates no Nutrition Transition)1. Processed foods >30 g/d < 30 g/d 2. Fried foods >30 g/d <30 g/d 3. Sugar‐sweetened beverages > 0 ml/d < 0 ml/d 4. Dairy > 500 g/d < 500 g/d 5. Fruits and vegetables < 400 g/d > 400 g/d 6. Breads > 25 g/d < 25 g/d 7. Simple sugars > 10% of total calories < 10% of total calories 8. Fat, total > 30% of total calories < 30% of total calories 9. Saturated fat > 10% of total calories < 10% of total calories 10. Cholesterol > 300 mg/d < 300 mg/d2 Dietary patterns using exploratory factor analysis and their factor loadings among adolescents in South India (n=198) aFood group Factor 1 ‘Transition Pattern’ Factor 2 ‘Animal foods pattern’ Factor 3 ‘Traditional Pattern’Breads 0.42 — — Global Unhealthy Foods 0.61 * — — Global Healthy Foods — — — Processed Foods 0.61 * — — Snacks — — — Fried Snacks 0.76 * — — Red Meat — 0.67 * — Lean Meat — 0.80 * — Eggs — 0.54 * — Sweets and Desserts 0.46 * — — Dairy — — 0.48 * Tea and Coffee — — — Fruit Juices 0.45 * — — Soda and Energy Drink * 0.54 * — — Fruits — — 0.49 * Vegetables — — 0.49 * Pulses and Nuts — — — Traditional Grains — — 0.47 * Fried Traditional Food 0.49 * — 0.42 * Sugar and Jaggery — — 0.58 * Ghee — — 0.43 * Eigen values 4.8 1.6 1.0 Variance explained (%) 3.0 2.2 20a Loading < 0.4 are designated with ‘—’. * Factor loadings greater than 0.4.3 Intake of food groups (g/d) among adolescents with and without Nutrition Transition diets (n=198)Food group (g/d) Nutrition Transition diet group (n=49) No Nutrition Transition diet group (n=149) T‐test Mean SD Median Mean SD MedianBreads 58.9 41.6 51.4 29.8 34.5 14.8 <.0001 Global Unhealthy Foods 67.9 53.6 50.4 15.4 22.1 8.5 <.0001 Global Healthy Foods 3.5 11.4 0.0 0.5 2.4 0.0 0.003 Processed Foods 59.3 35.5 53.4 25.3 20.2 19.6 <.0001 Snacks 59.1 40.1 52.6 31.2 32.7 22.2 <.0001 Fried Snacks 177.3 91.6 171.3 47.3 36.9 37.7 <.0001 Fried Traditional Food 37.6 23.9 31.6 19.1 15.7 14.2 <.0001 Sweets and Desserts 108.5 57.4 96.0 52.9 47.9 40.6 <.0001 Red Meat 5.7 11.3 0.0 4.1 9.8 0.0 0.33 Lean Meat 20.5 37.9 4.0 9.4 17.7 0.7 0.0058 Eggs 32.1 37.9 25.7 13.4 17.8 6.6 <.0001 Dairy 221.5 155.9 201.3 160.4 181.3 106.0 0.035 Tea and Coffee 202.8 139.3 200.0 144.5 100.5 142.9 <.0001 Soda and Energy Drinks 47.1 44.4 32.9 7.5 15.6 0.0 <.0001 Fruit Juices 109.9 74.2 85.7 46.4 56.6 28.8 <.0001 Fruits 147.4 75.9 136.7 97.2 82.4 78.3 0.0002 Vegetables 128.6 85.2 116.6 110.6 109.7 79.8 0.29 Pulse and Nuts 284.3 117.3 299.7 258.3 147.7 235.9 0.26 Traditional Grains 763.9 228.1 757.8 615.2 269.9 564.7 0.0006 Sugar and Jaggery 4.7 5.2 2.1 4.5 7.1 0.7 0.83 Ghee 1.3 1.9 0.3 1.3 2.9 0.3 0.92Evidence‐drive Nutrition Transition Diet Score 5.7 0.9 6.0 4.4 1.0 4.0 <.0001 Evidence‐drive Nutrition Transition Diet Score Range 4–81–6